Comment to: Valdez RS, Holden RJ, Novak LL, et al. Transforming consumer health informatics through a patient work framework: connecting patients to context. J Am Med Inform Assoc JAMIA Published Online First: 14 August 2014. doi:10.1136/amiajnl-2014-002826 In their paper “Transforming Consumer Health Informatics through a Patient Framework: connecting patients to context,”1 Valdez and colleagues propose a “patient-work” framework based on an holistic view of patient’s socio-environmental context that should streamline Consumer Health Informatics (CHI) application development and deployment. However, the proposed framework does not consider CHI applications as potential actors of the healthcare digital information flow, within the so-called “health-IT ecosystem” envisaged by the Health Information Exchange movement.2 In this letter, we propose a framework for the integration of CHI applications into the “health-IT ecosystem”. This is in line with the American Medical Association’s vision for improving electronic health record (EHR) usability by facilitating “Digital and Mobile Patient Engagement” through “interoperability between patient’s mobile technology and the EHR”.3 We believe that such integration is a fundamental pre-requisite for CHI applications that, together with the holistic “patient-work” design perspective, will lead to full adoption and effectiveness for better patient care. In the healthcare switch to a patient-centered and home-settled paradigm, self-care and self-management add new expanded responsibilities for patients, families, and communities. CHI has the potential to enable this scenario.1 CHI applications produce health information that is potentially relevant for patient’s assessment, physiological monitoring, diagnosis, therapy, and rehabilitation, and that could be beneficially integrated into health information systems, such as the EHR. This would avoid duplication and redundancy, as well as potential errors and misunderstanding. Figure 1 shows the architecture that we propose to ensure the direct exchange between CHI applications and health information systems. General architecture for the data exchange among CHI applications and health information systems. The patient-work framework1 is an essential building block of the architecture, ensuring that the CHI application is designed for and around the patient. However, other building blocks are needed to allow the interaction between CHI applications and health information systems, including the EHRs: Concept Translator: In the CHI-EHR exchange domain, the technical solution should take into account the “health literacy” issue. The efficacy of patient/doctor communication and the degree of the patient’s engagement in decision-making depends on the patient’s understanding of the healthcare process.4 CHI applications should ensure the proper concept mapping from the healthcare specialist domain to the patient/family domain. This is represented by the “concept translator” that can be implemented relying on experiences like the Consumer Health Vocabulary. Security Tools: Data protection policies should be transparent and clearly stated as part of a patient’s education and awareness.4 Standard Document and Communication Architectures: Both professional health information systems and CHI applications should follow a model-based development. The patient-work framework1 grounds the development of CHI applications, while healthcare process modelling should be at the basis of healthcare information system development. This will ensure the necessary flexibility to face different clinical settings (EHR-side) or socio-technical environments (patient-side). Communication standards for EHR-Personal Health Record (PHR) data exchange can be adapted for CHI applications. For example, the X-PHR Integrating the Healthcare profile provides the general transaction framework for EHR-PHR information exchange; the HL7 Clinical Document Architecture release 2 “Personal Health Monitoring Record” drafts a standard document architecture for exchanging personal monitoring information. Connection to Educational Tools. The application should include the connection to qualified information sources, such as MedlinePlus and PubMed. Feedback System. Appropriate logging systems able to collect user’s experience and feedback on the application should be included. The implementation of such building blocks ensures, as essential requirements for the interaction process, that (1) the information exchanged is accurate, as described in the ISO 13606 standard regarding healthcare information exchange, thus, preserving the original meaning intended by the author; (2) data are protected, accounting for confidentiality (protection from unwanted access), integrity (transmission and maintenance of accurate data), and availability (data accessibility and usability upon demand by authorized request), as well as accountability (traceability of responsibility on data content) and disaster recovery; (3) flexibility is guaranteed by interoperability, according to the “not-one-fit-all” concept,1,2,4 and considering both technological (eg, standard communication architectures), and semantic (eg, shared terminologies/ontologies) interoperability; (4) patient education is supported to both enhance “health literacy” and to create a “culture of custodianship”4 related to the nature of personal health information; and (5) research and evidence-based practice can be prompted thanks to the availability of information necessary for establishing the benefits and limitations4 of the CHI-EHR two-way exchange. The strong need of shared decision-making and patient’s contribution to their health records is demonstrated by initiatives, like OpenNotes,5 already allowing a more effective information exchange between patients and healthcare professionals. Complementary to these, the design, development, and deployment of CHI applications able to communicate with health-IT ecosystems through the proposed architecture will be the key for patient engagement in self-management and self-care.

We developed and implemented a 'CPOE-QT Alert' system, that is, clinical decision support integrated in the computerized physician order entry system (CPOE), in 2011. The system identifies any attempts to order medications with risk of torsade de pointes (TdP) for patients with a history of significant QT prolongation (QTc ≥500 ms) and alerts the provider entering the order. We assessed its impact by comparing orders and subsequent medication administration before and after activation of the system. We found a significant decrease in the proportion of completed order per ordering attempt after system activation (94% (1293/1379) vs 77% (1888/2453), difference 16.8%; p<0.001). This resulted in a 13.9% reduction in the administration of those medications to patients. A significant decrease was observed across all provider types, educational levels, and specialties. The CPOE-QT Alert system successfully reduced exposure to QT-prolonging medications in high risk patients.

As computing and network capabilities continue to rise, it becomes increasingly important to understand the varied applications for using them to provide healthcare. The objective of this review is to identify key characteristics and attributes of healthcare applications involving the use of advanced computing and communication technologies, drawing upon 45 research and development projects in telemedicine and other aspects of healthcare funded by the National Library of Medicine over the past 12 years. Only projects publishing in the professional literature were included in the review. Four projects did not publish beyond their final reports. In addition, the authors drew on their first-hand experience as project officers, reviewers and monitors of the work. Major themes in the corpus of work were identified, characterizing key attributes of advanced computing and network applications in healthcare. Advanced computing and network applications are relevant to a range of healthcare settings and specialties, but they are most appropriate for solving a narrower range of problems in each. Healthcare projects undertaken primarily to explore potential have also demonstrated effectiveness and depend on the quality of network service as much as bandwidth. Many applications are enabling, making it possible to provide service or conduct research that previously was not possible or to achieve outcomes in addition to those for which projects were undertaken. Most notable are advances in imaging and visualization, collaboration and sense of presence, and mobility in communication and information-resource use.

Early detection and removal of polyps can reduce mortality due to colon cancers. The "fly-through " method in CT colonography has drawbacks. We are developing a prototype colon straightening system so as to provide a paradigm to inspect the colon wall in a "cut-open " fashion. The core component of the system is the straightening module, which models the colon straightening as a solid elastic deformation process with specially designated constraints and boundary conditions. It is demonstrated that the prototype system can retain consistency of surface points' spatial relationship and handle geometry with large-degree bendings. Future work is discussed.

Cellular radio telecommunication has increased exponentially with many applications to health care reported. The authors attempt to summarize published applications with demonstrated effect on health care, review briefly the rapid evolution of hardware and software standards, explain current limitations and future potential of data quality and security, and discuss issues of safety.

A multipoint videoconference was webcast live to an audience who could communicate with conference panelists and each other via chat. The videoconference, webcast, and chat were done entirely over the Internet. Seven panelists at four conference sites that had Internet2 connectivity and were located in different time zones within the continental United States discussed the topic of "Evaluating Health Professions Education and Information Resources on the Web." This discussion was broadcast to individuals and groups at various U.S. locations who had expressed an interest in the topic and had sufficient connectivity for receiving the video stream. Webcast recipients could log on a chat server and type questions and comments to the panelists and other viewers. The experiment's rationale, procedures, and outcomes are described, and issues associated with the use of the technologies are identified.

The holy grail of modern medicine is the quest to achieve an all-inclusive lifelong health record. There has been long discussion as to what belongs in such a record. Advances in data storage devices have made such discussion irrelevant, The answer is: "store everything". The more timely and difficult question is the efficient and specific retrieval of the needed information from the stored data. This leads to questions of indexing schemes at storage time or natural language processing at retrieval time. One must remember that the lifelong record is not made up of just text. It is a multimedia record containing pictures (X-rays, MRI, pathology), signals (EEC, EKG), sounds (heart, bowels), and videos (echo cardiogram, angiogram). Bulk storage may no longer be a problem, but efficient, specific retrieval certainly is.

The Visible Human Project data sets are designed to serve as a common reference point for the study of human anatomy, as a set of common public-domain data for testing medical imaging algorithms, and as a testbed and model for the construction of image libraries that can be accessed through networks. The data sets are being applied to a wide range of educational, diagnostic, treatment planning, virtual reality, artistic, mathematical, and industrial uses by more than 800 licensees in 27 countries. But key issues remain in the development of methods to link such image data to text-based data. Standards do not currently exist for such linkages. Basic research is needed in the description and representation of image-based structures and in the connection of image-based structural-anatomical data to text-based functional-physiological data. This is the larger, long-term goal of the Visible Human Project: to link the print library of functional-physiological knowledge with the image library of structural-anatomical knowledge transparently into one unified resource of health information.

The title and theme of the 1996 AMIA Spring Congress was “Conquering Distance: Teleinformatics, Telemedicine, Telehealth.” In her welcoming statement, Betsy Humphreys, co-editor of this issue and Program Chair for the 1996 AMIA Spring Congress, wrote: High-speed, high band-width access to the Internet is spreading rapidly; the World Wide Web is providing cross-platform integration of text, pictures, and sound; and the technologies supporting telemedicine, informatics, public health, and education are converging. As enhanced communications help us to conquer geographic distance, they provide the opportunity to link informatics, telemedicine, public health and information services in new and powerful ways. This conference explores the links between teleinformatics, telemedicine, and telehealth by focusing on (1) the technologies themselves and practical considerations involved in their use; (2) current teleinformatics, telemedicine, and telehealth applications and the extent to which they integrate access to health data and knowledge-based information; (3) efforts to share and aggregate patient data across networks; and (4) public policy issues, including interstate licensure and privacy.

The National Library of Medicine's Visible Human Male data set consists of digital magnetic resonance (MR), computed tomography (CT), and anatomic images derived from a single male cadaver. The data set is 15 gigabytes in size and is available from the National Library of Medicine under a no-cost license agreement. The history of the Visible Human Male cadaver and the methods and technology to produce the data set are described.